Referral Pathways for Patient Care

The process of communicating with patients and between allied health care professionals must be smooth in order for us to deliver the best health outcomes, particularly when multiple pathologies are under management.

General practitioners, ophthalmologists and all other subspecialists in allied health care learn many of their skills together in the collective field of medicine. This leads to the organic development of professional relationships and referral pathways for patient care.

For optometrists, it’s a different story. Our learning is separate from the schools of medicine, and so, when working alongside medical professionals, we have to be mindful of the extra effort required to effectively communicate our complementary skill set, and thus, to ensure that together we can achieve optimal patient outcomes.

…communicating with patients… must be smooth in order for us
to deliver the best
health outcomes

The following case study illustrates the importance of clear communication.

The Modest Mr. R

The modest Mr. R was an active importer/exporter of niche products with a history of regular eye tests every few years since he was 40 years of age. Unfortunately, despite this, he had spent many years with undiagnosed glaucoma.

By the time he was referred to my practice, Mr. R had an extensive ocular history of advanced bilateral glaucoma, and was under the care of a glaucoma subspecialty ophthalmologist.

Secondary to glaucoma, Mr. R had a history of complications of bilateral endothelial compromise with symptomatic painful, erupting bullae blisters and fluctuating vision with Fuch’s dystrophy as a result of cataract surgery complications.

Additionally, Mr. R had a right central retinal vein occlusion, and so was under the care of a subspecialty retinal ophthalmologist for his regular anti-VEGF injections of Lucentis.

To add to his complications, Mr. R appeared to exhibit an extremely rare endothelial decompensation reaction when his anti-VEGF injection was changed from Lucentis to Avastin. This caused further corneal endothelial decompensation, and thus necessitated a Descemet’s stripping endothelial keratoplasty (DSEK) corneal graft in his right eye. With advanced glaucoma and Fuch’s dystrophy, I was advised that Mr. R’s vision in his left eye was reduced to light perception only.

Consequently, Mr. R was referred to me both from his corneal ophthalmologist and his regular optometrist for specialty contact lens management to maximise the remaining vision in his right eye.

Existing Visual Acuity

On the day of testing, Mr. R’s existing specs and visual acuity were as follows:

• Right eye: 0.00/-0.75 x 55 6/30.
• Left eye: 0.00/-0.75 x 54; counting fingers at 50cm.
• Due to the Fuch’s dystrophy, Mr. R’s right eye vision fluctuated between 6/18 on good days to 6/30 on his worst days.
• Mr. R was wearing Bausch + Lomb 8.6/14.0/0.00 Purevision 2, which served as a bandage contact lens for pain and symptoms management of his Fuch’s dystrophy in both eyes.

On the day of Mr. R’s testing a change in refraction yielded:

• Subjective Rx
• Right eye: +0.50/-1.00 x 20 6/18.
• Left eye: balance; counting fingers at 50cm
• K readings by Nidek autokeratometer showed fairly regular Ks
• Right eye: 8.00mm (42.18D) at 55; 7.88mm (42.82D) at 145; average Ks 7.94mm; corneal cyl -0.50D at 55

Management Plan

I advised Mr. R to get new spectacle lenses dispensed from his regular optometrist with the new prescription, given there was a consistent and significant improvement in his vision with the new refraction.

I pursued a change in his soft contact lens prescription in both eyes as a temporary measure and fitted him with specialty rigid lenses in his right eye for ongoing management.

In an effort to reduce any extra induced corneal oedema in an already fragile cornea, I was keen to prescribe a silicone hydrogel contact lens that offered maximum oxygen permeability, with a good performance track record and FDA approval for on-label extended wear. Therefore, I prescribed CooperVision Biofinity Toric; RE 8.7/14.50/+0.50/-0.75 x 20 6/15.

To minimise the risk of any infiltrative or infective events, Mr. R was advised there was to be strictly no extended wear.

Due to the corneal irregularity, I also triaged him for a range of rigid gas permeable lens options, taking into consideration RoseK2, Post Graft, Irregular Cornea and XL lenses.

I was keen to avoid prescribing a fully sealed miniscleral or scleral lens given Mr. R’s prior endothelial issues. I suspect that sclerals need an effective corneal endothelial pump to avoid corneal neovascularisation and other potential corneal complications. Keeping in mind the need to prescribe conservatively in his only seeing eye (an already complex eye with multiple conditions), I was keen to prescribe conventional RGPs if possible.

Out of RoseK2, Post Graft, Irregular Cornea Design and RoseK2 XL lenses, the RoseK2 XL exhibited the best fitting characteristics for Mr. R’s right eye.

The RoseK2 XL CL has characteristics like a miniscleral for vaulting over corneal irregularity, but exhibits tear exchange and has some properties more like a rigid lens, as it is supported on the cornea and conjunctiva overlying the sclera. RoseK2 XL achieved a good central and mid-peripheral fitting, but unfortunately the larger corneoscleral lens diameter made the superior lens edge impinge on the trabeculectomy drainage bleb (figure 6).

However, as it compensated well for the corneal irregularity on his right cornea, the BCVA on trial improved one to two lines to 6/12.

Usually notching a contact lens would allow it to steer well clear of the drainage bleb and affect the intraocular pressure. Notching for RoseK2 XL CLs has only just become available at the time of print of this article.

Future management will be choosing between tailoring the central and midperipheral basecurves to make a conventional rigid lens work, or notching a RoseK2 XL contact lens.

Overall Management

During the consultation, Mr. R mentioned that although he felt his eyecare practitioners were extremely competent, every one of them had assumed he understood his pre-existing conditions and had automatically gone into ‘fix-it mode’.

He said he experienced modest improvement in vision and comfort with the contact lens, and he certainly appreciated that in his position, every little bit counts.

However, he said the biggest benefit he had received from his consults with me was his new understanding of all of his eye conditions – I had taken the time to carefully explain each of the conditions and the role each eyecare professional was taking in managing those conditions.

After all these explanations, the overarching message Mr. R had been left with was the importance of maintaining appointments with all of his eye care professionals to ensure he received the very best care for his multiple complex conditions.

Conclusion

Whether a patient’s eye health is simple or complex, it is critical that there is a strong foundation of effective communication to preserve their vision.

As optometrists, we have to be mindful of the extra effort required to ensure effective communication with our fellow colleagues. A well-written follow up report allows all other health care professionals involved in the patient’s management to effectively fulfil their role.

Additionally, we must take the time to educate our patients about the need to have regular eye tests, the importance of being screened for conditions such as glaucoma, about maintaining ongoing appointments and complying with treatment regimes.

Nelson Mandela says, ‘Education is the most powerful weapon which you can use to change the world.’ If we educate our patients on what we do and why, we can preserve the vision and quality of life of our patients.

After all, every little bit counts.

Margaret Lam is an optometrist with practices in greater Sydney and Sydney CBD. Margaret practises full scope optometry, but with a passionate interest in contact lenses, retail aspects of optometry and successful patient communication. She has extensive experience in specialty contact lens fitting in corneal ectasia, keratoconus and orthokeratology, and is a past recipient of the Neville Fulthorpe Award for Clinical Excellence.

Margaret writes ‘mipatient’ on alternate months wth Jessica Chi.